Braden Scale Question on Nutrition

highlandlass1592, BSN, RN · Nov 24, 2008

One of the questions on a nursing exam we took today involved proper use of the Braden Scale. It was pretty straightforward except the nutritional aspect. This patient was said to be unresponsive and therefore NPO. However they were on TPN at 20ml/hr. We had quite a discussion after class. Some felt that the TPN meant that the Nutritional Score would be a 3, while others felt that the NPO status took precedence over the TPN and should score a 1. Still others felt like 480 mL of TPN did not provide enough hydration or nutrition and that the patient was still scored a 1. Because the scenario said our patient was also overweight, some felt like this bumped the score back up to a 3. Help?!! Our text has very little on the Braden score, and the website wasnt very helpful on clearing this up. Can anyone give me some help with this or point out some resources that I can research more on scoring a scenario like this in the future? Thanks!

LOL don't get too wrapped up in Braden...some facilities don't even use it. That being said, a couple of things to consider: pt's weight isn't always a good indicator of nutritional status: a pt can be fluid overloaded and be malnourished. Just something to keep in mind. And the volume of the TPN isn't always an indicator of proper nutrition: you'd need a breakdown of what was in the TPN to determine if nutritional needs were being met.

All that being said: with what you've presented, I'd say the nutrition was at a 3...TPN was being provided and assuming it was mixed to meet nutritional needs you'd get that score. And if that is the rationale you used and you get it wrong, I'd argue the point. :wink2: Oh, I've found a direction sheet for Braden, explains the rationale for the points: http://www.scribd.com/doc/2374539/Braden-Score It's a bit difficult to read with the small print but you can enlarge it. I don't know if you have that or not.

Another point to remember about Braden: it is a SUBJECTIVE assessment. You can have two nurse perform the assessment and get drastically different scores. Don't beat yourself up about it. Good luck in your classes.

dymnback · Nov 24, 2008

That makes sense...Thank YOU! Also good advice...the instructor keeps reminding us "Think like a nurse!" and honestly...sometimes I just dont know HOW a nurse thinks...lol! I appreciate the help!!!

highlandlass1592, BSN, RN · Nov 25, 2008

That makes sense...Thank YOU! Also good advice...the instructor keeps reminding us "Think like a nurse!" and honestly...sometimes I just dont know HOW a nurse thinks...lol! I appreciate the help!!!

Well, gotta be honest with you. Learning to think like a nurse IS hard. You have to learn to critically think..and a key to that is to learn to think a problem through. That will be a challenge for you as you progress in your nursing career. Keep at it, and remember: the only stupid question is one that isn't asked.

PS: And don't get wrapped up in those nursing tests. They can really play with your mind. :-) Just keep plugging away and you'll do fine.

Reno1978, BSN, RN · Nov 25, 2008

This link should help:

http://www.bradenscale.com/braden.PDF

If a patient is on a tubefeed or TPN protocol that meets most of their nutritional needs, they'd be rated as 3 or Adequate.

TPN is started to meet the patient's nutritional needs. Yes, 480mL doesn't sound like a lot, but given the scenario you presented, you would just be reading into the question too much if the argument is that they aren't getting enough TPN. Without nutritional information about the contents of the TPN, that argument cannot be won.

blondy2061h, MSN, RN · Nov 25, 2008

I usually put TPN as a 3. NPO only counts as that if they're NPO and not getting anything to make up for it. However, you also need to use your own judgement. If they're only NPO for 8 hours before a procedure, obviously they don't have "very poor" nutrition. If they're eating full meals but throwing them all up afterwards, they're not "excellent" for nurition.

Most people on TPN are meeting their minimal needs, but certainly not over excelling. We've kept people NPO but on TPN for lllllooooonnnnggggg periods of time with GVHD and they usually don't lose a whole lot of weight.

liv2b · Mar 25, 2009

agreed with everyone above. you are about to get the long answer. j

i'm a student involved in updating some skin risk assessment policy. the facility uses braden for as an indicator in relation to intervention performed, yada yada yada. bunch of hostility from the nurses on the floor about 'more paper work' (it's a good 10 min getting through all the clicking...) and how it is 'worthless' in identifying risk.

it is. but a tool just provides a systematic way to look at skin risk and the qualifying factors that must be considered. the facility's definitions are based off reno's link [bradenscale.com] where they also provide interventions [http://www.bradenscale.com/newlevels.htm]. notice on interventions how it says to bump up risk if 'other risks are present." i.e...hip fracture, major surgery, "advanced age, fever, poor dietary intake of protein, diastolic pressure below 60, or hemodynamic instability." what about crone's disease or bowel surgery...their taking it in but with a 2 in gut, not much you can do. per the tool, tpn is a 3 on nutrition...many places fail to use the fudge factor of 'other risk.' any one of the risk factors on the scale may only take one point off or be well above 18 but is the cause of the ulcer forming.

like those crazy care plans they have you do in school, the braden is all about systematic assessment so you don't over look something. at this facility, they use it to triggers nutrition consults (less than 3 on nutrition), ambulation/turning/30-degree positioning protocol (less than 3 for sensory, activity, or mobility), bowel and bladder training/linen changes(less than 3 for moisture), etc. the final score is calculated but you can still change the risk with the 'other risk factor' action to trigger consult with the wound care team. fyi- braden is always done with a complete skin assessment and looking at your pts skin.

long term care (ltc) is different than acute care in terms of skin assessment. ltc has a bad rap because they can have poor ratios and not meet the needs of interventions. since ltc is not acute, nearly all of these ulcers are preventable. ulcers are major in-house complications, like pneumonia (get on your puffy), and medicare isn't paying for them anymore.

a lot of ulcers are formed in acute care settings as well by the "other factors" previously mentioned, but also, it is generally given a low priority (note medicare isn't paying anymore). check behind head (pillow's not so soft after a while), ears (use foam on oxygen tube), bottom, or heels. nobody likes the anti-embolic stockings (ted hose, or the sequential compression device (scd) but that could help the low flow. remember: diabetes is the 1# cause of lower limb amputations.

:rolleyes: i got a little excited there. good luck!

blondy2061h, MSN, RN · Mar 25, 2009

I check the orders for how many calories the TPN is providing. If it's only providing 500 calories, and they're not eating, they get a 2 from me. If it provides, say 2000 calories, and they're not eating, they get a 3.

Generally speaking, our guidelines is TPN gets a 3, tube feeds gets a 2, NPO w/ no feeds or just clears for an extended period gets a 1.